The Science of Addiction

Addiction is a brain disease, not a choice, says the American Society of Addiction Medicine

Described in the Alcoholics Anonymous Big Book as "cunning, baffling, powerful," addiction often seems as inscrutable as the human mind itself. Its reach is widespread: Else Pedersen, executive director of Bridge House, estimates 10 to 15 percent of the population has an addiction. "We all either have this or have some strong primary connection to it," she says. "This is everywhere, and it needs to be dealt with like the medical issue it is. We need to give it the same attention we give other diseases that are progressive, pervasive and potentially lethal."

Last month, The American Society of Addiction Medicine (ASAM) made a big step toward widespread recognition of addiction as a medical issue rather than a behavioral issue or moral failing. It released a new definition which states addiction is a chronic, underlying, largely genetic brain disease.

"The disease is about brains, not drugs," former president of ASAM Dr. Michael Miller stated in a press release. "It's about underlying neurology, not outward actions." Miller oversaw a four-year effort by more than 80 addiction experts and neuroscience researchers which yielded the new definition.

"This is a definition based on a consensus of expert opinion and scientific literature that changes the understanding of addiction from a choice or a self-treatment to a condition of brain structures that basically compels behavior outside the ability to choose," he says. "It's also pivotal in the sense that it equates a compulsion to use chemicals with compulsions to have other kinds of behaviors such as food or gambling or sex. (It is) the same disease state. Addiction is not a choice."

The new definition reveals addiction to be a primary disease, much like diabetes or cardiovascular disease. It can be a root cause behind other behavioral, social and psychological problems like depression, cognitive distortions, social isolation and anxiety. According to ASAM's definition, "genetic factors account for about half the likelihood that an individual will develop addiction" — meaning if one of your parents is or was an addict, you are genetically predisposed to developing addiction.

Since addiction has physical, neurobiological causes, one would expect the brains of addicts to function differently than the brains of non-addicts. This is exactly what happens, says Dr. Howard Wetsman, medical director at Townsend, a network of local outpatient addiction treatment centers. Many (not all) addicts have a morphology (or mutation) in the genes associated with the production, release, reuptake and metabolizing of dopamine, a neurotransmitter associated with pleasure and reward. Wetsman refers to the intricate factors governing normal dopamine levels as "dopamine tone."

"Generally, people who have a low dopamine tone are not able to make great attachments and feel rewards from normally rewarding activities, and that is when the drug or behavior comes along," he says. " Our society likes to think that drugs cause addiction. It's actually the other way around for most people with addiction. The addiction causes the drug use," he writes in his book, QAA: Questions and Answers on Addiction.

The genetic factor is so pervasive that Wetsman has instituted genetic testing as part of Townsend's intake procedure. "The test identifies two dozen genetic mutations in the brain that relate to symptoms of addiction," says John Antonucci, an intake coordinator at Townsend who also is recovering from addiction. "This information helps fine-tune medical interventions, and it is amazing when you take a patient and their family members, and they realize it really is a biological brain disease. I like to equate it to seeing the X-ray when you have a broken arm. And I have seen family members break down and cry when they realize all this time, their kids weren't doing this to spite them. They were doing it because they were sick."

Though Antonucci says nine out of 10 of Townsend's patients report addiction in their family trees, there are some addicts without a family history or genetic indication of the disease (but because addiction can express itself through many different compulsions, from overeating to compulsive spending, it can sometimes be hard to trace, Wetsman says). New Orleans native, Xavier University alumnus, father of five and recovering addict Darryl Rouson, now a Florida state representative, had no known family history of addiction.

"My mother was known to cut her beer with 7-Up, and my dad drank three or four times a year," says Rouson, who began drinking and using cocaine in the '80s. "I wasn't drinking for the social nature, I wanted the effect, and I wanted it quickly, and for a long time. For me, it started out filling what I thought were voids in my life, low self-esteem: I never thought I was cute enough, strong enough, athletic enough or smart enough, and I was always doing things to compensate for these lacks."

Rouson says he has been through eight treatment programs and is well-versed in the genetic component of addiction, but he has never been tested for the morphologies. Though genetic testing can provide clarity to a diagnosis of addiction, and a basis for what medications will best normalize individuals' brain chemistry, neither testing nor medications are necessary for recovery. "There are millions of people who have gotten sober by going to 12-step meetings (like Alcoholics Anonymous or Narcotics Anonymous). For some people, that works," says Jo Cohen, clinical director of New Orleans Bridge House and Grace House. "We support the science, but like everything else in treatment, it's an individualized approach."

Although people do not choose to become addicts, they do have choices over how they manage the disease. Addiction requires ongoing treatment, which varies from person to person — some may benefit from ongoing use of medications like Suboxone, some may require long-term inpatient treatment, others may stay sober simply by attending 12-step meetings. Antonucci stresses that a strong routine of recovery-related activities like meetings or volunteering helps people maintain sobriety, as does access to help from addiction doctors. "This is a chronic disease like diabetes or hypertension," he says. "If you are diabetic, you get exercise and take insulin, but there are times you need to check up with your endocrinologist."

Rouson manages his addiction by attending 12-step meetings, sponsoring other recovering addicts, reading Alcoholics Anonymous literature, and giving back to the community by sharing his story at prisons and recovery centers. He will speak at Xavier Wednesday, Sept. 14, to celebrate National Recovery Month.

"One of the critical reasons why I got clean was I was given a choice," he says. "(My wife) Ruby was dead and I had taken her $80,000 life insurance policy and spent $60,000 on cocaine. I was in a courtroom with my wife's family and they were trying to convince the judge to take my four-year-old son. The judge said I could either choose Daniel or drugs, but after today, I would not have both. I chose my son."

Antonucci and Rouson both say their community outreach work, which is a tenant of Alcoholics Anonymous (the 12th step states, "Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs"), is essential to their ongoing sobriety. And though there may seem to be a disconnect between the scientific, biologically based addiction definition and the spiritually based 12-step programs, ASAM's research scientically supports the activities recovering addicts undertake in 12-step recovery programs as ways to maintain sobriety.

"Our medical approach to addiction dovetails very nicely into 12-step recovery, because there is a scientific basis behind how it works," Antonucci says. "Part of my recovery is, I serve food to homeless people every Saturday night, and afterwards, I feel great. Why do I feel great? My hedonic tone has gone up. Doing something really healthy for the community has changed my brain chemistry."

Wetsman agrees that engaging in charitable activities can normalize dopamine levels. "You get dopamine lowering from being isolated and feeling less-than," he says. "You can't feel isolated and less than when you help somebody else — dopamine receptors actually physically gain in number. The receptors are much more plastic than we think."

Pederson, Antonucci and medical professionals across the board hope the new definition of addiction will serve to remove much of the shame and stigma surrounding the disease, which in turn will facilitate recovery for the millions who suffer from addiction.

"When people have a strong understanding about the disease, that's when the miracles happen, and treatment can be extremely successful," Antonucci says. "Don't be afraid to get better. This can work for you, too. Give yourself a chance."